As Charlie Baker said, “The election is over.” But considering mental illness was a narrative of Martha Coakley’s campaign, I feel like this issue needs to be addressed, not because I keep hearing it everywhere I go, but because I do a lot of research on a myriad of topics, and don’t have an issue speaking out on these things I research.

During Attorney General Martha Coakley’s campaign for Governor this year, we heard speak of her brother, Edward, who had depression and committed suicide. This is the ad produced by the campaign:

This is generally a very sweet and thoughtful video. During the video Martha Coakley mentions that a lot of people come up to her and tell her that “this was my brother,” “it was my spouse,” and “that was my daughter.”

This Boston Globearticle from November 2013 describes a more in depth look at this:

Although Massachusetts has made great strides in providing quality health care to most residents, there is more work to be done, Attorney General Martha Coakley is set to say in a speech Friday. In particular, the state needs to increase access to mental health treatment, an issue that is deeply personal to Coakley: Her brother committed suicide in 1996.

Coakley, who is running for governor, has rarely spoken about his death during her long career as a public official, though she has brought it up more frequently in the past few years.

“My younger brother Edward was a brilliant person — he was smart, funny, a great pianist. He also suffered from depression,” she is set to say in a speech at the Massachusetts Association of Health Plans’ annual conference in Boston. “When he was 33 years old, he committed suicide.”

“It is why I know first-hand — as many of you do — that behavior[al] health care is as vital to the treatment of many patients as physical health care,” Coakley is set to say, according to a copy of draft remarks provided to the Globe by her office.

Though the speech is being given in her capacity as attorney general, campaign aides believe the issues she will speak about — a call for greater parity in mental health care and for reducing the stigma of mental illness — are likely to be part of the policies she will highlight in her gubernatorial campaign.

Before his death, she said her brother worried that if he got mental health treatment, he would never find a job. The irony, Coakley said, was he was never able to get a job because he did not get mental health treatment. Coakley said the experience of losing him has prompted her push to reduce the stigma of mental illness.

One way to begin to do that is by increasing public awareness, which is why she said she has spoken about her brother’s suicide publicly more often in recent years. “I’ve done it more frequently because I recognize that every time I do, people always come up to me afterward and say: my child, my brother, my parent,” she said. “I recognize how much families and individuals still think they’re the only ones and they suffer in silence.”

Although, I have no issues with acknowledging a generalization that Coakley’s brother had mental health issues, as he was not my brother or family member, I find a strong need to critique the two above portions of this.

First, Coakley says that she has “first hand” about how behavioral health is as a vital treatment of many patients, but I’m aware that Coakley isn’t a psychologist or psychiatrist to actually know these things. Those are doctors specifically trained to work with it more closely with the topic than Coakley would as the state’s attorney general. She has a degree in law, not mental health, period.

The second part I highlighted can be summed up more from the European Archieves of Psychiatry and Clinical Neuroscience, titled Do people with mental illness deserve what they get? Links between meritocratic worldviews and implicit versus explicit stigma:

Mental illness stigma is common and remains a major burden on individuals with psychiatric disorders, their families and caregivers, further increasing the impact of mental illness on society. Stigma can seriously undermine the clinical course, quality of life and well-being of people with mental illness. People with mental illness are often held responsible for their condition, a view that reflects a common prejudice and important target for current anti-stigma initiatives aiming to reduce public stigma and its impact on people with mental illness. Widely endorsed ideologies in western societies can explain why stigma against people with mental illness is so persistent. A better understanding of how these worldviews are associated with stigma can therefore improve anti-stigma efforts. This applies to public anti-stigma interventions as well as to attempts in clinical or self-help settings to reduce self-stigma and its burden on people with mental illness.

Meritocratic worldviews hold that individuals are personally responsible for the outcomes they experience (‘‘They are to blame for their depression and should just pull themselves together’’). These common beliefs can justify status differences in society, such as discrimination against people with mental illness, and give individuals the reassuring feeling that the world is fair and they have control over their lives. Typical examples include the Protestant ethic, which stresses the necessity of hard work and personal responsibility, and the belief in a fundamentally just and fair world. Just world beliefs reflect the view that people get what they deserve and deserve what they get.

These worldviews can influence public attitudes toward stigmatized minorities and attitudes of stigmatized minorities toward their own group. For instance, endorsing the Protestant ethic was found to be associated with more racist attitudes among members of the public. As a parallel phenomenon among stigmatized individuals, increased endorsement of the Protestant ethic led to lower self-esteem in overweight women. With respect to just world beliefs, research has shown an important distinction between beliefs in a just world for self (‘‘I get what I deserve’’) and just world beliefs for others (‘‘Others get what they deserve’’). Just world beliefs for others, as an index of meritocracy ideology and similar to Protestant ethic, are associated with more stigmatizing attitudes toward minorities. On the other hand, just world beliefs for self can be a coping resource for stigmatized individuals and are therefore not only associated with increased well-being and self-esteem, but specifically with reduced distress in response to social devaluation or unemployment.

In terms of measuring stigmatizing attitudes, a recent review on just world beliefs pointed out the benefit of incorporating indirect measures that are not influenced by self-presentational strategies and that may capture biases of which individuals are not fully aware or able to report accurately. Indirect measures use reaction-times to detect implicit-automatic associations between, for example, ‘Mental Illness’ and ‘Guilt’. Such measures can also assess subtle manifestations of ingroup blame among stigmatized individuals, a possible consequence of endorsing meritocratic ideologies. Indirect measures are also less susceptible to strategic response distortions and self-presentational strategies and therefore particularly helpful in work on stigma, where participants may hesitate to openly endorse stigmatizing statements. Furthermore, indirect versus deliberate responses often independently predict outcome variables, again particularly in the domain of stigma. Attitude researchers have therefore become increasingly interested in implicit-automatic aspects of cognition and have documented many dissociations between rapid, automatic reactions and more thoughtful, deliberative ones. Persons with or without mental illness may automatically associate ‘Mental Illness’ with ‘Guilt’ and thus implicitly harbor guilt-related negative stereotypes about mental illness. Automatic and deliberative aspects of stigmatizing attitudes can predict different kinds of cognitive, affective, and behavioral tendencies and may respond differently to attempts to reduce stigma. In the current study, we employed the Brief Implicit Association Test (BIAT) to measure implicit guilt-related stereotypes about mental illness. To the extent that people believe in personal responsibility for one’s life outcomes, they may automatically associate persons experiencing mental illness with guilt. Despite extensive research on other stigmatized groups and initial evidence supporting a link between personal values and endorsement of mental illness stigma, we are not aware of any studies on meritocratic worldviews and prejudice against people with mental illness. We therefore examined the link between meritocratic worldviews and mental illness stigma, among both members of the public and people with mental illness. Although implicit and explicit attitudes are hypothesized to relate to meritocratic worldviews similarly, they are nevertheless expected to be relatively uncorrelated with one another.

We set out to examine the following hypotheses. First, we expected stronger endorsement of the Protestant ethic to be associated with more negative implicit and explicit attitudes toward people with mental illness in both groups, including a positive correlation between endorsing the Protestant ethic and self-stigma in persons with mental illness. Second, among members of the public, we predicted that increased just world beliefs for others would be related to more stigmatizing implicit and explicit reactions toward persons with mental illness. Third, we assumed that among individuals with mental illness just world beliefs for self would be negatively correlated with self-stigma as an index of stigma-related distress.

As highlighted above, along with the second highlighted portion of the Boston Globe article, there seems to be a strong presence in the language that victim-blaming has taken place in that narrative. “It was Edward’s fault for not seeking mental health care and this lead to his suicide.” Interestingly enough, by October of this year, her stance seems to have made a reversal:

For Coakley, helping those with mental illness is public policy grounded in personal tragedy. Her brother, who was bipolar and refused medication, committed suicide in 1996.

“Eighteen years later now, after he took his own life, I have seen and heard too much and from too many families about the stigma attached to getting treatment,” she said.

What did the study conclude?

Despite these limitations, our study provides initial evidence that endorsing the Protestant ethic is associated with more negative attitudes to people with mental illness, among individuals with and without mental illness and including implicit guilt-related stereotypes among members of the public. Just world beliefs for self may help people with mental illness to better cope with discrimination, but may come at the price of increased implicit blame against people with mental illness. Our findings have implications for attempts to reduce public stigma in society as well as self-stigma in people with mental illness. Future anti-stigma campaigns that aim to reduce public stigma might want to address meritocratic worldviews that could maintain stigma in society, especially the notion of perceived responsibility of people with mental illness for their condition. Research suggests that worldviews can be primed. By activating a different worldview (e.g., in a public service announcement) that acknowledges both the role of factors outside an individual’s control in shaping their outcomes and the ability of many people to successfully recover from a mental illness, corresponding shifts in attitudes and behavior could be anticipated. To the extent that people are repeatedly exposed to primes of an alternative worldview, that worldview would be expected to gain psychological potency. One area where these kinds of effects have been shown is in the domain of cultural worldviews. Still, it will be difficult to change worldviews that are deeply engrained in society. In our view, though, it would be realistic and helpful to achieve two more circumscribed aims. First, anti-stigma work could spread awareness that meritocratic worldviews may augment stigmatizing views, especially in terms of perceived responsibility of people with mental illness for their condition and thus reduce the automatic assumption that people with mental illness fall under the general rule that they deserve their fate. Second, the public could be informed that, similar to common views about persons with physical illnesses, individuals with mental illness do not deserve what they get.

Interventions to reduce self-stigma and its impact on people with psychiatric disorders, whether in group trainings run by professionals, peer-support programs, or individual settings using narrative approaches, could also take common worldviews into account and discuss their consequences for self-stigma among people with mental illness. Persons with mental illness may have internalized meritocratic worldviews which increases their vulnerability to internalize negative stereotypes about their own group. The effect of worldviews on attitudes toward others and oneself may operate openly, for example, in deliberately endorsed statements about blame, but also in more hidden and automatic ways, for example, in spontaneous or non-verbal behaviors. The latter type of reactions depends on more automatically activated associations, for example, between Mental Illness and Blame, which can be assessed by indirect measures such as the BIAT. Therefore, it may help to increase the collective awareness of the pernicious effects of these automatically activated reactions when addressing self-stigma. In summary, initiatives designed to reduce public or self-stigma face the difficulty that widely endorsed meritocratic ideologies may augment mental illness stigma both as endorsed in explicit statements and through automatically activated associations, adding to the resilience of stigmatizing attitudes. Increased awareness of these cultural factors will help us to successfully tackle stigma in its many forms.

Television and the Social Stigma

Although most of us are pretty well aware that most television is completely fictionalized representations, this doesn’t preclude others from falling into the trap that maybe some part of what is being displayed is possibly true, if not inspired by a very real phenomena or story. Take Girl. Interrupted…

Of course, as I have said, this is a completely fictionalized representation, sensationalized to get earnings at the Box Office. The actors in the movie, are real people, playing characters written by someone, and then altered to fit a movie format.

From the North American Journal of Psychology, June 2014, titled The stigmatization of people with a history of mental illness by those who admire celebrities:

In the last decade there has been a proliferation of research on persons who are enthralled with celebrities–persons who have been termed “celebrity worshippers.” More than two dozen studies using a reliable and valid measure of interest in celebrities have appeared in print, and we now know quite a bit about those who admire celebrities. For example, those who are absorbed or addicted to their favorite celebrity are also prone to narcissism (Ashe, Maltby, & McCutcheon, 2005), likely to have poor mental health (Maltby, Houran, & McCutcheon, 2003; Maltby, McCutcheon, Ashe, & Houran, 2001), and show addictive and criminal personality traits (Sheridan, North, Maltby, & Gillett, 2007). Given the serious implications stemming from this line of research, it behooves us to learn as much as possible about celebrity worshippers.

Another of the generalizations that has emerged from this body of research is that about 75% of the favorite celebrities chosen by study participants are actors, musicians, or athletes (Green, Griffith, Aruguete, Edman, & McCutcheon, 2014; McCutcheon, et al., 2004). These favorites are almost always entertainers who appear frequently on television and other social media. Thus, it seems reasonable to assume that many Americans spend so much time on social media that it heavily influences their choice of a favorite celebrity. Persons who have made noteworthy contributions to literature, medicine, religion and science are much less often shown on television, and when they are, they are typically shown briefly as part of the news or as a guest for a few minutes on a talk show. In a recent study, only six participants out of 248 chose favorite celebrities from one of these four humanitarian categories (Green, et al., 2014). Thus, it could be argued that television and other social media are not only instrumental in providing celebrities, but also in swaying the public toward the choice of an entertainer as a favorite celebrity. Indeed, a study that identified the favorite celebrities of young adults showed that 83% of them fell into the entertainer categories (actor, musician, athlete), and that many (e.g. Tom Cruise, Brad Pitt, Michael Jackson, Michael Jordan, Jerry Rice) appeared frequently in social media (Boon & Lomore, 2001).

Information obtained from television news and programming, along with movie portrayals, doubtless shapes the worldview of millions who are dedicated viewers in other ways, as well. The stigmatization of persons who have had mental health problems has been widely attributed to the way these individuals have been portrayed on television and in movies (Diefenbach, 1997; Granello, 2000; Granello, Pauley, & Carmichael, 1999; Klin & Lemish, 2008; Philo, Secker, Platt, Henderson, McLaughlin, & Burnside, 1994; Stout, Villegas, & Jennings, 2004; Stuart, 2006; Wahl, 1997; Wilson, Nairn, Coverdale, & Panapa, 1999). Studies show that exposure to media portrayals of mental illness leads to misconceptions about crime and a lack of tolerance toward persons with mental illness (Granello, 2000; Granello, et al., 1999; Stout, et al., 2004; Stuart, 2006). Wilson et al. (1999) found that the criminal offense rate of mentally ill characters who had speaking parts in televised dramas was ten times greater than it was for other television characters. Wahl (1997) found that public images of mental illness contained an excessive association with comedy and violence. More specifically, Philo and colleagues (1994) found that two-thirds of media content dealing with mental health linked mental illness with violence, and two-fifths of a general sample believed the link was realistic; further, they cited the media as the source for their belief. Wilson et al. (1999) identified ten themes in television dramas relating to mental health stereotypes, nine of which were negative. The two most common themes were dangerousness and unpredictability.

Collectively these findings show that social media have contributed to the stigmatization of persons who have a history of mental illness. Furthermore, stigmatization has negative consequences for the stigmatized. Bos, Kanner, Muris, Janssen, and Mayer (2009) showed that stigmatization has a detrimental effect on self-esteem, life satisfaction, employment opportunities, and income, while Link (1987) found that former mental patients tend to devalue themselves and expect to be stigmatized, and Klin and Lemish (2008) found that the fear of being stigmatized prevents people from getting the mental health care that they need.

Most of the favorite celebrity choices come from the ranks of entertainers who appear often on social media–the same social media that promote misconceptions about the dangerousness of people with mental illness or a history of psychiatric hospitalization. We hypothesize that there will be a positive relationship between scores on a measure of devaluation of mental health consumers and scores on a measure of attitudes towards one’s favorite celebrity, and a one-item measure of attitudes toward celebrities in general. That is to say, because of the influence of social media on choice of favorite celebrity and stigmatization, we believe that those who most admire their favorite celebrities and celebrities in general will be those who tend to most devalue mental health consumers. We further hypothesize that there will be a positive relationship between scores on a measure of devaluation of mental health consumers and the frequency of watching television entertainment shows, such as Entertainment Tonight, Access Hollywood, and E!.

The old saying goes, “It Must Be True!”

It’s true, there is no such place as Wyoming. This video was seen on TV! Believe it?

From the Psychiatric Times, November 2013, titled The Painted Bird: stigma and mental illness:

As the boy in Jerzy Kosinski’s 1965 book, The Painted Bird, wanders about Eastern Europe fleeing the Nazis who have entrapped his Polish parents, he witnesses an event that is apocryphal in its depiction of stigma. He comes upon a professional bird catcher who paints a captured bird with many colors, and then releases it to the sky. The boy watches as the soaring, painted bird comes upon its flock and is mercilessly attacked by its own. The bird plummets, dead, to the earth below.

At a moment when mental health is so much at the forefront of the minds of Americans and our media, it seems time, again, to try to understand the damaging views so commonly held about people with mental illness. Trustworthy information tells us that people with serious mental illnesses are no more dangerous than the general public–if their condition is treated and they are not abusing alcohol or drugs. In fact, people with mental illness are far more likely to be victims of violence than they are to be perpetrators. In addition, ample evidence also exists that effectively managed mental illnesses need not be barriers to fulfilling and lasting relationships and to achieving career aspirations.

Yet, equally compelling evidence tells us that people fear, avoid, and otherwise stigmatize those with mental illnesses despite the fact that a bird remains a bird even if its feathers are painted. A new study sheds more light on this complex phenomenon and may better direct efforts at its elimination.

The American Journal of Public Health recently published, online, a study (one of a group of papers) on stigma and discrimination against those who suffer from mental disorders. (1) Individuals from the US, Europe, Asia, and Africa (16 countries in all) were asked to read a short vignette describing a person with either schizophrenia or depression. While symptoms were clearly portrayed (such as paranoia, agitation, and hearing voices in one case, and sadness, difficulty in concentrating, and feeling worthless and discouraged in the other), no diagnostic label was offered, nor was sex or race, thus reducing other potential biases.

Study participants were queried about their knowledge about mental conditions, including whether it was a brain disease and whether treatment can work. They were also assessed for stigma with questions about reluctance to interact with the person described, whether mental illness renders people “inferior” or dangerous, and whether someone would experience unwanted consequences if he or she were revealed to have a mental disorder.

This study demonstrated that while there is generally widespread understanding about mental illness, “rejecting … notions of individual weakness … [and] moral failure,” there was a “backbone” of stigma: People with mental illness were seen as having potential for violence (especially toward themselves) as well as problems meeting role responsibilities for children (eg, caring and teaching), and they were undesirable for marrying into families. While schizophrenia was more likely to be seen as a brain disease than was depression, there was greater stigma toward people with schizophrenia, including their social inclusion and meeting role responsibilities.

The CDC released complementary findings in a 2010 study of more than 200,000 adults in 35 states, the District of Columbia, and Puerto Rico who were asked about their attitudes toward mental illness. They showed that despite generally positive public attitudes that mental health treatment works, those with mental illness continue to feel that others are not “caring and sympathetic.” In other words, they still feel excluded among their own flock despite a public knowledgeable about mental illness and its treatments.

I’m sure that I join many of you in being disappointed, but not surprised, by the findings of a recent Indiana University-Columbia University study, published in the online American Journal of Psychiatry last month, that found no change in prejudice toward people with serious mental illness or substance abuse problems, despite years of research that have uncovered and helped explain the neurobiological basis of these illnesses. The stigma was measured by, among other things, questions about respondents’ willingness to “work closely” with individuals with schizophrenia, major depression, or alcohol dependence.

These findings hit home for me when I remembered the outstanding plenary session offered by pharmacologist Carlton Erickson, PhD, one of the nation’s most respected addiction science researchers, at September’s National Conference on Addiction Disorders (NCAD). Erickson started his session by recounting the words of a prominent acquintance who, in reference to Erickson’s body of work, said: “I don’t believe addiction is a disease. Every once in a while something like this comes along to kill off the weak people.” When asked to consider the likelihood that an addiction would impact a member of his own family, the acquaintance replied, “The hell it will.”

The gasp in the audience was audible.

Dr. Erickson went on to explain that, with regard to addiction, many people are skeptical over the status of addiction as a “disease” because they experience those who call themselves addicts when their issue is actually one of misuse or abuse, due perhaps but not exclusively to bad personal judgment. Such a person, he explained, certainly has a problem but “doesn’t have what it takes”–genetic and other as yet unrecognized factors–that cause the brain disease that is real addiction. Regardless, this confusion makes the common bias easier to maintain. So, despite a measurably better understanding of the brain disorder involved, 74 percent said that they would be unwilling to work with an alcohol-dependent person.

The bias against the mentally ill is more subtle. Everyone, it seems, is sensitive to their plight, but there’s a real NIMBY (not in my backyard) reaction when the mentally ill move a little closer to home, as I observed in my July/August 2010 editorial, “What kind of people will be living here?”

The study shows there’s plenty of bias in the workplace as well. Consider the range of behavioral tools and consulting services sold to businesses today–including personality tests, evaluations, coaching, and the like. In dedicated and caring hands, tools such as these can promote good working relationships, inspired leadership, honest dealing, and personal growth. But in the hands of the presured or impatient, these tools can become a means for labeling, then winnowing out, those whose differences can be uncomfortable or inconvenient–the anxious, the insecure, the impulsive, the moody, the awkward, the quirky but brilliant.

Which brings me back to the study results: The researchers suggest that stigma reduction efforts shift away from emphasis on the involuntary mechanisms and symptoms of addiction or disease and instead recognize the strengths, abilities, talents, and diversity of individuals affected by mental illness or addictions.

Sure makes sense to me. It is these personal qualities–along with courage, fortitude, and access to treatment–that make recovery, employment, and a “normal” place in our diverse society possible.

And since most of us are not mental health experts or professionals, what we call something is a very careful thing to consider, as described in this Mental Health Practice, April 2009 article titled The name game: we must be careful when using labels to describe people with mental health problems:

IT WOULD be awful to be told that you have a personality disorder. Imagine coming home from seeing your psychiatrist and thinking to yourself: ‘Am I disorderly or is my personality out of order?’

Although the days of the Victorian asylum are long gone, the ripples of stigma still circulate and diagnostic labels can have adverse effects on service users.

The mental health charity Mind says that such labels reduce a broad range of human experience to symptoms of illness (Mind, 2007).

Less than a century ago the terms idiot, imbecile and lunatic were used as clinical labels in psychiatric hospitals. Many people were hospitalised simply for breaking social norms that had nothing to do with any medical diagnosis.

When we use the term ‘personality disorder’, which covers a spectrum of conditions or behaviours, we are in danger of using derogatory labels in the same way our predecessors did.

This term is used when there is gross disparity between a person’s behaviour and the prevailing social norms.

It is characterised by at least three of the following:

* Callous lack of concern for the feelings of others.

* Gross and persistent attitude of irresponsibility and disregard for social norms, rules and obligations.

* Incapacity to maintain enduring relationships, though having no difficulty in establishing them.

* Very low frustration tolerance and a low threshold for discharge of aggression, including violence.

* Incapacity to experience guilt and to profit from experience, particularly punishment.

* Marked proneness to blame others, or to offer plausible rationalisations, for the behaviour that has brought the patient into conflict with society.

Avoidant personality disorder

This is characterised by at least three of the following:

* Persistent and pervasive feelings of tension and apprehension.

* Belief that one is socially inept, personally unappealing, or inferior to others.

* Excessive preoccupation with being criticised or rejected in social situations

* Unwillingness to become involved with people unless certain of being liked.

* Restrictions in lifestyle because of need to have physical security.

* Avoidance of social or occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval or rejection.

Alternative terms

These two conditions are very different, so placing them under the umbrella term ‘personality disorder’ is unacceptable.

Perhaps more appropriate, friendlier diagnostic labels could be created, such as ‘avoidant condition’ instead of avoidant personality disorder, or maybe ‘isolation preference’ rather than the term schizoid personality disorder.

As well as reducing stigma, better labels could describe each individual’s condition more accurately. We should always be aware of how we would feel in the service user’s situation and treat them the way we would like to be treated.

This article from The Advocate (American Mental Health Counselors Association) November 2013 titled International study reveals core of mental illness stigma states the following:

An international study found that despite widespread acceptance that mental illness is a disease that can be effectively treated, prejudice unfairly paints people with conditions such as depression and schizophrenia as undesirable for close personal relationships and positions of authority. This prejudice spanned the 16 diverse countries examined.

“If the public understands that mental illnesses are medical problems, but still rejects individuals with mental illness, then educational campaigns directed toward ensuring inclusion become more salient,” the authors wrote.

The researchers analyzed data from the Stigma in Global Context–Mental Health Study, which talked with 19,508 study participants about customized vignettes. The vignettes portrayed someone suffering either from depression, schizophrenia or, the control group, asthma. The countries represented a diverse range geographically, developmentally, and politically, with at least one country on each inhabitable continent.

Even in countries with cultures more accepting of mental illness, stigma was detected, encompassing issues involving caring for children, marriage, self-harm, and holding roles of authority or civic responsibility. The stigma was even stronger toward people with schizophrenia.

“With the prevalence of mental health problems being so high, no individuals or families will go untouched by these issues,” said Bernice Pescosolido, PhD, sociology professor in the Indiana University College of Arts and Sciences. “They need to understand that recovery is not only possible but has been documented.“

This very lengthy article, which should be completely read through, from the Journal of the American Psychiatric Nurses Association (JAPNA), October 2007, titled Stigma, poverty, and victimization: roadblocks to recovery for individuals with severe mental illness:

Individuals with severe mental illness (SMI) want the same outcome as individuals with medical illnesses. They want recovery (Ahern & Fisher, 2001). For a long time, the accepted outcome for patients with SMI has been stability pursued through emphasis on patient compliance with medications, prevention of hospitalization, and patient and family adaptation to a chronic, lifelong illness; but now, stability has been replaced by the concept of recovery that has gained wide acceptance by psychiatric nurses and other care providers (Lysaker & Buck, 2006; Roe, 2005). Recovery is both a process and an outcome in which patients return to or acquire for the first time a meaningful social role, develop relationships, reclaim a sense of self-identity, and become members of their communities (Ahern & Fisher, 2001). Recovery evolves from the interaction of patients’ unique attributes–self-efficacy, hope, and purpose in life–and the services, supplies, supports, and opportunities that are available to them in the environment. For individuals with SMI, major roadblocks to recovery are the pervasive influence of stigma, the overarching effect of poverty, and the more direct effects of victimization. The purposes of this article are (a) to describe the adverse effects of stigma, poverty, and victimization; (b) to provide information that will enable psychiatric nurses to build advocacy skills; and (c) to identify strategies that psychiatric nurses can use to reduce stigma and help their patients cope with poverty and reduce the risk of being victimized.

STIGMA

Stigma is often defined as a mark of shame, disgrace, or disapproval that results in discrimination against individuals who are deemed deserving of disapproval and in their being shunned, rejected, or excluded (Arino, 2004). For people with severe mental illness, stigma is the greatest barrier to having a complete and satisfying life (Canadian Mental Health Association, 2001; Yanos, Rosenfield, & Horwitz, 2001). It leads to inadequate health insurance coverage, fear and mistrust by others, prejudice, discrimination, and exclusion.

Stigma surrounding mental illness is deeply ingrained and reinforced by media portrayals of individuals with mental illness as unpredictable and dangerous (Benbow, 2007). Although the effects of stigma are often subtle, permeating many areas of an individual’s life, there are also more direct effects such as discrimination in the workplace and restriction of housing options. Opposition in community neighborhoods to the creation of housing such as group homes for individuals with mental illness is widespread and is known as “Not in My Back Yard” (NIMBY; Borinstein, 1992, p. 187). According to one survey, nearly two thirds of respondents would not welcome a group home for individuals with mental illness in their neighborhood, and three fourths would not welcome independent apartments (Borinstein, 1992). These attitudes create walls of exclusion that prevent individuals with SMI from obtaining safe, comfortable housing and becoming part of a community (Borinstein, 1992). Stigma is also encountered daily by individuals with SMI as they deal with public-sector bureaucracies, health care professionals, merchants, service providers, and managers of restaurants and coffee shops (Forchuk, Nelson, & Hall, 2006).

POVERTY

Poverty, defined by Wilton (2004, p. 26) as “having insufficient money, goods or means of support,” has far-reaching, direct effects on individuals’ lives and well-being. It affects their ability to meet their basic needs and to participate in educational, leisure, social, and community activities (Wilton, 2004). Poverty creates barriers to one of the first steps of recovery–patients’ accepting responsibility for pursing all that they can be (Deegan, 1993).

Studies have consistently demonstrated a negative relationship between socioeconomic status and mental illness (Costello, Compton, Keeler,& Angold, 2003). There have been conflicting views of whether poor socioeconomic situations create a vulnerability to develop mental illnesses (the social causation theory) or whether individuals with mental illness relocate to poorer socioeconomic situations because of their illness (the social selection or downward drift theory). Using data from the records of 34,000 patients who had been hospitalized more than once on acute psychiatric units between 1994 and 2000 and the U.S. Census Bureau’s long-form data, Hudson (2005) tracked patients’ relocations and found that among all psychiatric patients with three or more hospitalizations during a period of 21/2 years, the rate of those moving to lower socioeconomic situations was the same as the rate of those moving to higher socioeconomic situations. Among a subgroup–those with schizophrenia, often thought to be one of the most severely disabling of the psychiatric disorders–there was a slightly higher rate of moving to lower socioeconomic situations (17.2%) in comparison to moving to a higher socioeconomic situation (15.2%), a 2% difference. Hudson’s study does not support the downward drift theory. He suggests that the increased rate of mental illness associated with low socioeconomic status may be explained by a social-economic-stress model in which the stress associated with adverse circumstances such as poverty, unemployment, and inability to afford safe housing influences the development of mental illness. In a similar vein, Goldberg (2005) says that poor people are more likely to face threatening, humiliating, and entrapping life events that undermine their self-image and leave them feeling deprived of control over their lives.

Ware and Goldfinger (1997) believe that among individuals who develop mental illness, poverty is associated with enormous stress. After paying for housing, these individuals have very little left to cover other expenses (Wilton, 2004). They struggle and use strategies for managing with insufficient financial resources, such as careful budgeting; shopping at thrift stores and outlets; borrowing money from landlords, mental health care providers, family, and other patients; going without; selling their monthly bus pass; pawning personal items; panhandling; and shoplifting (Wilton, 2004). Ware and Goldfinger (1997) describe poverty as a formidable obstacle for individuals with SMI to overcome.

POVERTY AND UNMET NEEDS

The psychiatrist Hansell (1976) describes basic needs as seven life-supporting interactions with the environment that are cantilevered and consist of (a) basic survival supplies–oxygen, food, clothing, water, shelter, being safe, health care, communication, transportation, and information; (b) a firmly held sense of self-identity; (c) close contact with at least one person; (d) membership in a group or groups that claim the individual as a member; (e) roles in life that provide opportunities for achieving self-esteem and dignity; (f) money–some form of purchasing power; and (g) a sense of meaning of life experiences. According to Hansell, each interaction with the environment supports all other interactions. One failed interaction, one unmet need, affects the satisfaction of all other needs, the individual’s ability to adapt to stressors, and his or her overall well-being.

The greater the degree of poverty, the greater is the number of unmet needs of individuals with SMI (Wiersma, 2006). More unmet needs are associated with lower quality of life and with poorer health (Wiersma, 2006). Individuals with SMI living in the community have the same basic survival needs as those without mental illness, but they also have needs related to their illnesses or disabilities, such as the need for case management; mental health care including crisis interventions; appropriate, safe, supportive housing such as group homes; and sheltered employment (Malm, May, & Dencker, 1981; McCrone et al., 2001; Torrey, 1988). When unmet needs were measured among individuals with SMI, each unmet need had a negative correlation with life satisfaction. Three unmet needs–personal identity, safety, and money–were found to have a negative correlation not only with quality of life but also with psychiatric hospital admissions and psychiatric emergency room use (Perese, 1997). Although the ability to meet all needs is influenced by poverty, the ability to meet certain needs–housing, personal safety, leisure activities, finances, and transportation–that are crucial for recovery of individuals with SMI is especially affected by poverty.

Need for Basic Survival Supplies

Shelter or housing. More than half of individuals with SMI are not satisfied with their living situations (Kowalchuk, 2003). They want safe, stable, affordable, and desirable housing that is appropriate for their level of functioning and located near the supports and services that they need (Forchuk et al., 2006; Kowalchuk, 2003). Home is where many everyday activities take place, and Borg et al. (2005, p. 243) write that “having a home affords a sense of order, identity, connectedness, warmth, haven and physical protection.” In a survey of patients who had been committed to involuntary outpatient treatment under New York’s Kendra’s Law, women often talked about their dreams for a home, even if it was only one room that was just for them, a place where they could have a shelf and keep their things in order, and men often talked about their dreams of having a home where they could keep a dog (Perese, Wu, & Ram, 2005). A home that is safe provides continuity and security when an individual with SMI experiences changes or losses of services and supports, such as loss of counselors or case managers. Having a home provides a sense of connectedness with the neighborhood, and at the same time, a private sanctuary that they can return to when they wish (Borg et al., 2005). Security and stability of a home allow individuals with SMI to structure their time, to give meaning to their life, and to have control over some part of their life through activities that they choose, such as watching television, having a cup of coffee when they want, or decorating their home. These activities are important steps toward recovery (Borg et al., 2005).

Mental health care. Medicaid has become the single largest payer of mental health services for low-income people. However, not all low-income people with SMI are eligible for Medicaid. They may not be eligible because they are not disabled enough to qualify for supplemental security income, because they are not single adults or immigrants, or because they are homeless, incarcerated, or too ill to follow through with enrollment and eligibility processes (Cunningham, McKenzie, & Taylor, 2006). Unmet need for mental health care is caused not only by inability to pay for services but also by gaps in services and supports for individuals with SMI– shortages of staff, especially psychiatrists, and long waiting times before receiving services; shortages of therapeutic living situations such as group homes and transitional shelters; and lack of psychiatric inpatient beds for acute care (Cunningham et al., 2006). The effect of unmet need for care is seen in high rates of homeless mentally ill individuals, psychiatric emergency room visits, and mentally ill individuals in jails and prisons (Cunningham et al., 2006). Because there are not enough inpatient beds for acute care, individuals who need constant supervision are often incarcerated. Arboleda-Florez (1999, p. 677) writes, “In many cities, the large number of mental patients in local jails has made the jail a practical extension of the general mental health services.” Jail has become a “de facto institution for the mentally ill” (Cunningham et al., 2006, p. 697).

Transportation. Poverty limits the ability of individuals with SMI to obtain transportation. An unmet need or partially met need for transportation affects all aspects of their lives. In one study, more than half of individuals with SMI (55%) said that they did not have the transportation that they needed (Kowalchuk, 2003). Lack of transportation limits their choice of housing, access to health and dental care, and their ability to go out, to be with friends, to shop, and to take advantage of opportunities that could move them toward recovery (Borg et al., 2005).

Personal safety. Poverty’s adverse influence on personal safety is primarily through its restriction of the ability of individuals with SMI to afford safe housing in low-crime neighborhoods. In a 1-year period, 30% to 40% of individuals with SMI are victimized (Perese, 1997; Teplin, McClelland, Abram, & Weiner, 2005; Walsh et al., 2003), and those who have been victimized do not believe that they can keep themselves safe from revictimization (Walsh et al., 2003). Perceived inability to protect themselves against robbery or attack is highest among women and individuals who are homeless (White, Chafetz, Collins-Bride, & Nickens, 2006).

Need for Self-Identity

A sense of self-identity is tied to the familial, social, and vocational roles that individuals fulfill, and although mental illness and residual disabilities may have affected the ability of individuals with SMI to perform certain roles, poverty also affects their self-identity through its influence on their readiness to undertake new roles. Roles provide a purpose to life, and being able to meet the expectations for each role builds a role identity. Accumulated role identities are associated with increased sense of self-esteem, self-worth, and self-identity (Cohen, Doyle, Skoner, Rabin, & Gwaltney, 1997). Lack of a sense of self-identity is high among individuals with SMI. For example, 54.8% identified an unmet need for a sense of self-identify (Perese, 1997). Poverty-linked inability to have transportation and appropriate, clean, and well-fitting clothing that would enable them to meet role expectations is associated with a reduced sense of self-esteem and of “not fitting in” (Wilton, 2004, p. 35). Turner-Bowker (2001) points out that clothing is important to one’s presentation of self to others and to one’s self-esteem. Because of lack of financial resources, individuals with SMI often buy their clothing from thrift shops that may not have clothing that is appropriate for young adults or clothing that will fit them. Individuals with SMI believe that cheap, ill-fitting clothes and the inability to obtain hair cuts when needed are visible signs or markers of their mental illness that all can see (Dear, Gaber, Takahashi, & Wilton, 1997). An unmet need for self-identity results in a diminished sense of being worthy of love and support, in being afraid of failure and rejection, and in giving up (Roe, 2005).

Need for Persons, Groups, and Roles

The need for connectedness with persons, groups, and roles is frequently unmet among individuals with SMI. For example, among a group of individuals with SMI, 61.6% identified an unmet need for a friend, 56.2% for a group to belong to, and 60.3% for a role in life (Perese, 1997). Individuals with SMI do not have adequate financial resources to participate in leisure activities with others. Instead, they tend to engage in solitary leisure activities: going to a coffee shop, going for a walk, going to the movies, going to the mall, watching television, going to the park, eating at a fast food restaurant, and riding the bus. Some spend most of their time watching television in their residences (Wilton, 2004). Development of new social networks and maintenance of existing social networks is affected by the unmet need for financial resources. The unmet need for money to pay for transportation to visit family, to buy gifts for family special events, or to contribute toward family gatherings–to be a reciprocating member of a social network–leads to social withdrawal and feelings of being disconnected (Wilton, 2004).

Need for Money

Money makes it possible to take advantage of opportunities that could move a person toward recovery, such as activities that promote engagement in the community through hobbies, participating in sports, or having a pet to walk. For many individuals with SMI, after the cost of housing is deducted from their monthly Social Security income check, they have about $120 left to cover the cost of clothes, shoes, toiletry articles, haircuts, cigarettes, food, newspapers, transportation, going for coffee, and video rental fees (Wilton, 2004). Among 114 individuals with SMI surveyed, 95% said that they could not make it through the month (Kowalchuk, 2003).

VICTIMIZATION

Victimization occurs more often for individuals with SMI than for the general population (Goodman et al., 2001); the rate of victimization of individuals with SMI is 12 times higher (Teplin et al., 2005). Victimization experienced by individuals with SMI includes verbal abuse, bullying, threats, theft, physical assaults, and rape (Teplin et al., 2005). Victimization can occur through violent behaviors perpetrated by others including partners and family members, by exploitation, by neglect, and by abuse by care providers. Patients with SMI living in the community who have been discharged from psychiatric hospitals and psychiatric institutions say that the hospitals and institutions were no safer than the community. There, danger came from other patients, some of whom committed assaults, and from staff. Individuals with SMI say that they prefer the dangerousness of their lives in the community to the dangerousness of psychiatric hospitals and institutions (Eisenberg, 2005).

Risk factors for victimization of individuals with SMI include history of childhood neglect and abuse, being male and younger than 40 years of age, living in transient situations or being homeless, less than daily contact with family, early onset of mental illness, higher level of symptoms, lower level of functioning, comorbid personality disorders, experience of victimization in adulthood, having a history of violent behavior, frequent contact with the law, use of illegal drugs (but not of alcohol), lack of social support, and more unmet needs (Hiday, Swartz, Swanson, Borum, & Wagner, 2001, 2002; Walsh et al., 2003). The disabilities associated with SMI–impaired cognition and judgment, limited problem-solving skills, and impulsivity–also increase the risk of victimization (Perese, 2007). The adverse effects of victimization experienced by individuals with SMI include (a) exacerbation of existing disorders; (b) increased use of psychiatric services, both increased hospitalization and increased use of psychiatric emergency rooms; (c) decreased quality of life; (d) increased risk for revictimization; and (e) increased risk for perpetration of violence by the individual victimized (Teplin et al., 2005).

Victimization by Violent Behaviors of Others

The lifetime rate of sexual abuse among individuals with SMI is known to be very high: nearly two thirds (64%) of women and one fourth (26%) of men. The lifetime rate of physical abuse is also high: 37% for women and 49% for men (Goodman, Rosenberg, Mueser, & Drake, 1997). Current or recent victimization is also shockingly high. Among women with SMI, 79.4% had been physically assaulted by a partner or relative within the previous 12 months (Cascardi, Mueser, DeGiralomo, & Murrin, 1996), and among homeless women with SMI, 33% had been physically or sexually assaulted within the preceding 30 days (Goodman, Dutton, & Harris, 1997). Individuals with SMI are at high risk of being victimized by partners or family members. For example, on admission to a psychiatric hospital, 63% of patients with a dating partner reported physical victimization in the previous year–hitting, punching, choking, or being beaten up or threatened with a knife or gun–and nearly half (46%) of those who lived with family members reported being physically victimized in the previous year. Among those reporting violence from a dating partner, 75% retaliated, and of those reporting violence from a family member, 59% retaliated (Cascardi et al., 1996). This finding supports the view of Hiday et al. (2001) that victimization is a link between mental illness and perpetration of violent behaviors.

Victimization by Neglect or Omission of Care

In studying the health care of individuals with SMI living in group homes, it was found that both the residents and the group-home staff lacked knowledge and ability to maintain the residents’ health. Furthermore, the staff members did not believe that health maintenance and health promotion for the residents was their responsibility. The residents were unaware of what constituted a healthy diet, how to control weight gain, the benefits of exercise, and how to stop smoking. They were worried about contracting sexually transmitted diseases and lacked information about prevention but were reluctant to ask their counselor or the group-home staff. Although the group homes had protocols in place to monitor residents’ medically based preventive interventions and to record recommendations for care, such as low-salt and low-calorie diets and increased activity, the recommendations were often filed away, and residents were not helped to carry out the recommendations. The staff members lacked the skills to help the residents modify lifestyle practices, and they did not believe that health teaching related to sexually transmitted diseases was part of their job. The result, although unintentional, was neglect of the residents’ health and risk for exposure to sexually transmitted diseases (Getty, Perese, & Knab, 1998).

Victimization by Exploitation

Eisenberg (2005) says that individuals with SMI who live in urban slums are victimized by legal criminals: money lenders who charge very high interest rates; hotel keepers who demand bribes for rooms; bullies who accost them for money when Social Security Insurance (SSI) checks arrive; and police who do not defend them. Individuals with SMI also are exploited by the availability of gambling opportunities in their neighborhoods, places that sell “scratch-off cards” for $1.

Victimization by Care Providers

Since the 1960s, privately run state-regulated adult homes have evolved to provide housing for individuals with severe mental illness who, in the past, would have been cared for in state psychiatric hospitals. In New York State, approximately 15,000 patients live in 100 or more adult homes, some of which are as large as some psychiatric hospitals in the country (Levy, 2002a, 2002b). Adult homes are required to provide meals, activities, and supervision and to arrange for medical and psychiatric care by bringing in outside providers. The original assumption was that patients discharged to adult homes would learn to live independently in the community and become part of mainstream community life. A year-long investigation of adult homes in New York by a reporter for the New York Times portrayed devastatingly different outcomes. The patients were neglected; living in dirty, vermin-infested, unsafe situations; and financially and sexually exploited, harassed, threatened, and abused. In the large adult homes that were investigated, patients lived in a world without adequate health care, supervision, nutritional meals, planned activities, or assistance to prepare for mainstream life. They lived in a world of drug use, loan sharking, prostitution, violence, abuse, and early death (Levy, 2002a, 2002b).

IMPLICATIONS FOR NURSING

Psychiatric nurses must ask themselves what they can do to help individuals with SMI move toward recovery. Encumbered with psychiatric symptoms, impaired functioning, and residual disabilities related to their illnesses, individuals with SMI, valiant refugees from a fractured mental health care system, face stigma, poverty, and victimization in their quest for recovery. Psychiatric nurses can help by participating in evidence-based practices such as assertive community treatment. They can use their advocacy skills to reduce stigma, poverty, and victimization. Most importantly, psychiatric nurses can join individuals with SMI in working toward their goal of recovery.

Assertive Community Treatment

Assertive community treatment (ACT) is a treatment approach that provides services for individuals with SMI who have not had their needs met with other treatment approaches. It is well accepted as a comprehensive psychosocial treatment program designed for individuals with SMI and is advocated for by the National Alliance on Mental Illness (NAMI) and others as a best-practice form of treatment (Spollen, 2003). ACT is provided by a team of mental health professionals that includes psychiatric nurses. The team collaborates with others– rehabilitation and vocational training specialists, primary care clinicians, peer counselors, and others– to provide comprehensive individualized care that has recovery as the primary goal. Outcomes of ACT have been found to include improvement of psychiatric symptoms, psychological distress, stress, dangerousness to self (suicide), overall health, housing stability, and satisfaction with life as well as a trend toward improvement of unmet needs (Perese et al., 2005). There was some improvement of functioning but no significant improvement of employment, social support, and dangerousness to others (Perese et al., 2005). Psychiatric nurses in ACT programs have the skills to help patients improve functioning and increase their social support networks. Psychiatric nurses should also be prepared to advocate to have more of their patients’ needs met and for greater access to supportive employment programs.

Building Advocacy Skills

Psychiatric nurses can help by becoming advocates for reduction of stigma; the accompanying discrimination against housing, employment, and health care; and the apathy against community integration for individuals with SMI. Advocacy is standing up for something you believe in. Effective advocacy requires strong advocacy skills. Advocacy skills include

* ability to articulate what others are unable to express for themselves;

* ability to reframe problems in ways that others can understand and accept;

* being realistic and practical about developing strategies and formulating solutions;

Psychiatric nurses can build these advocacy skills by first developing a strong commitment to the cause of mental illness. Then, they must learn all they can about the issues. They can develop their communication skills by participating in presentations and discussion groups. They can seek mentors from among those with strong advocacy skills, and they can volunteer to work with others who are advocating for mental illness (Forchuk et al., 2006).

Reducing Stigma

The first step for psychiatric nurses to take in reducing stigma associated with mental illness is to be aware of the factors associated with the development of stigma against those with mental illnesses. Known factors include the following (Bolton, 2003):

1. Use of labels to identify individuals, such as a schizophrenic rather than a person with schizophrenia;

2. Observing patients with SMI who are experiencing symptoms and side effects of medications and engaging in socially inappropriate behaviors;

3. Attribution of the cause of mental illness to the individual; for example, the belief that mental illness is imaginary, reflects a weakness of character, or is self-inflicted;

4. Negative and incorrect information about mental illness, such as inaccurate information about violence among people with mental illness and incorrect information about the outcome or course of mental illness (information that does not reflect evidence-based data about positive outcomes and recovery); and

5. Lack of contact with people with mental illness.

Psychiatric nurses can reduce the stigma of mental illness by examining their own attitudes; updating their information about mental illnesses; listening to what patients and families say about the experience of having a mental illness; not using stigmatizing language and not allowing others to use it; and becoming an advocate (Bolton, 2003).

Fighting Stigma With Protest, Education, and Contact

Corrigan and Gelb (2006) describe three processes that can be used to challenge public stigma of mental illness: protest, education, and contact. In the protest approach, stigma is presented as a moral injustice, and the public is told not to act in this socially inappropriate way. Protest involves boycotting stigmatizing behaviors, business practices, presentations, and advertisements and using methods such as those of NAMI’s StigmaBusters (NAMI, 2007). NAMI StigmaBusters is a group of 15,000 or more advocates across the country and around the world that fight inaccurate, hurtful representations of mental illness in print, film, television, the Internet, and advertisements (Corrigan & Watson, 2004). Many psychiatric nurses participate in their local NAMI StigmaBusters programs. The goal of StigmaBusters is to break down the barriers of ignorance, prejudice, and discrimination by promoting education, understanding, and respect. For example, to promote respect for individuals with SMI, NAMI urges the use of “people first” language– for example, people with schizophrenia and people with clinical depression. Local groups of advocates deal directly with local radio and television programs, newspapers, and businesses that use discriminatory or offensive language or portrayals of people with mental illness. For example, in 2000, StigmaBusters played a role in removing a program, Wonderland, that portrayed people with mental illness as dangerous and unpredictable, and in 2007, StigmaBusters requested that Lions Gate Entertainment stop the marketing of the comedy Wristcutters and that a Super Bowl commercial showing a robot committing suicide be modified. StigmaBusters also sends letters of appreciation to those who provide an accurate portrayal of persons with mental illness and of the challenges they face (Corrigan & Gelb, 2006).

Education changes stigma by providing accurate information to replace stereotypes and myths. The educational approach uses books, flyers, lectures, movies, videos, presentations, panel discussions, and other methods such as the Internet (Corrigan & Gelb, 2006). For example, the author and other psychiatric nurses attend health fairs at local schools to teach about mental illness, the effect of stigma, and how the students can join the battle to decrease stigma and discrimination. Integrating mental-illness messages into television shows such as Law & Order and films such as A Beautiful Mind may also be helpful in reducing stigma. Education has been found to have a short-term influence on thinking and attitudes but little influence on changing behaviors (Penn & Couture, 2002).

Contact, the most effective of the three approaches, involves increasing public contact with individuals with mental illness. It involves interactions of individuals with mental illness with the general public such as presentations by individuals with mental illness about mental illness and recovery. An example of an ongoing contact intervention in which the author participates is a local NAMI Christmas Is for Kids project. NAMI members, individuals with mental illness, and their families meet with community leaders–religious leaders, service groups, student groups, social groups, merchants, and others–and ask them if they would like to participate in filling the wish lists of local children with mental illness. Change in attitude nd behavior is evidenced by the community’s continuing and expanding support of the project. Combining education with contact appears to be more effective than either approach alone with improvement of attitudes and behaviors that last (Corrigan & Watson, 2004; Evans et al., 2005). Examples of a combined education and contact approach are the provision of mental health awareness training to general-practice clinicians, police, and people in the volunteer section of health care providers by individuals with mental illness and the presentation of educational programs for school-aged children by individuals with mental illness (Highland Users Group, 2007).

Coping With Poverty

Poverty is an alternative explanation to that of the medical model of psychiatric symptoms and impaired functioning as the reason why individuals with SMI do not engage in social and community activities (Yanos et al., 2001). Viewed from that perspective, poverty should be included in assessment and treatment planning and addressed as part of the recovery process (Ware & Goldfinger, 1997). The only source of income for many individuals with SMI is Social Security Insurance, which is about 75% of poverty-level income (Barlas, 1992). Thus, the income of many individuals with SMI is below the poverty level of the general population. This level of poverty creates disparities in housing and ability to take advantage of opportunities that would enable people with SMI to become integrated into their communities (McCabe et al., 1993). The goal of psychiatric nurses is to increase their patients’ financial resources or substitutable supplies so that they can have nourishing food, safe housing, appropriate clothing, and access to social activities (Wilton, 2004). Ware and Goldfinger (1997) described strategies that psychiatric nurses could implement that have the potential to increase needed financial resources. One strategy is to stretch income by pooling money to buy in bulk, and another is the use of discount coupons. Another suggestion is that organizations or group homes set up a fund from which individuals with SMI can borrow money instead of borrowing from loan sharks at exorbitant rates (Ware & Goldfinger, 1997).

Reducing Victimization

Disadvantaged and disabled persons are known to be vulnerable to neglect and abuse. Therefore, individuals with SMI should be assessed for victimization as part of the psychiatric interview (Walsh et al., 2003). They should be monitored for victimization at each visit and evaluated for posttraumatic stress disorder (Teplin et al., 2005). They should receive information about factors that can be changed to reduce their risk for victimization (Teplin et al., 2005). For example, it has been suggested that interventions such as crime prevention programs–similar to programs for acquaintance rape and family violence–and teaching “street smarts” may be effective in reducing victimization. Psychiatric nurses are in a position to develop such programs, implement them, and evaluate their effectiveness. At the mental health care level, providing safe housing is crucial in preventing victimization. Other interventions with known effectiveness are assertive community treatment and programs that promote adherence to treatment for psychiatric symptoms and decrease substance use. Other interventions that may be helpful include skill-based programs and community survival programs. Strategies that can be shared with patients with SMI for reducing the risk of victimization are presented in Table 1.

TABLE 1. Strategies for Reducing Risk of Being a Victim
1. Be aware of what is going on around you.
2. Don't walk alone in dark places.
3. Walk near the curb.
4. Walk away from a tense situation.
5. If someone is bullying you, notify someone in authority.
6. Watch your body language; for example, look alert, walk with a
purpose.
7. Avoid stairwells.
8. Stand near the front of the elevator.
9. Do not tell anyone that you live alone.
10. Do not give your address to people you don't know.
11. Carry bus fare.
13. If someone is following you, run or yell, "Fire."
14. If someone is attacking you, yell, "Call 911," and keep on
yelling it.
Source: Adapted from Personal Security Tips, City of Nichols Hills,
Oklahoma, Nichols Hills Police Department. Retrieved from
http://www.nicholshills. net/page/asp?navid=223 on 9/5/2007.

Skill-based prevention programs to help patients learn skills to minimize risk of victimization can be included in the treatment plan. In addition, programs for those who have been victimized, such as those for acquaintance rape or family violence, can be modified to use with individuals with SMI who have been victimized. Treatment of substance abuse disorders among individuals with SMI would reduce vulnerability to victimization, and risk for revictimization (Teplin et al., 2005). Police can be trained to manage crime victims among the severely mentally ill. Perhaps most importantly, availability of emergency housing must be increased so that individuals with SMI are not homeless (Teplin et al., 2005).

Promoting Recovery

Because SMI affects all aspects of an individual’s life–physical and emotional well-being, social relations, work, and sense of self-identity (Roe, 2005)– individuals with SMI must recover from multiple traumas, losses, and deficits of functioning (Davidson, Stayner, & Haglund, 1998). Within the model of recovery, the objectives are that individuals with SMI will

* return to a meaningful social role,

* develop relationships,

* develop or reclaim a sense self-identity, and

* become a member of the community (Ahern & Fisher, 2001).

Individuals with SMI have identified what they need to move toward recovery. The first step is meeting their basic needs (health care, housing, finances adequate for living, transportation, means of communication [telephone], personal safety from abuse and victimization, social connectedness, a job, a sense of self-identity, and a purpose in life). Second is the fostering of hope that is shared by their families, care providers, and the community. Third is a holistic approach to promoting total health. They specifically ask that “best practice” program elements such as psychosocial interventions, health care, supported work, and self-help resources be available for them (New York State Office of Mental Health, 2003, p. 9).

Recent studies from different countries–Japan, Germany, Switzerland, and the United States–have shown that one half to two thirds of people with severe mental illness achieve significant recovery over time (Harding & Keller, 1998). How can psychiatric nurses help individuals with SMI achieve their goal of recovery? Individuals with SMI need to rebuild their connections–personal, social, environmental, and spiritual–to reclaim a sense of self and to actively take care of themselves by doing things that make their life work better, such as getting up on time, keeping appointments, shopping for and preparing their food, and planning activities. Psychiatric nurses can help by

* focusing on how the person feels and what he or she wants rather than on symptoms;

One of the strongest agents in recovery for individuals with psychiatric disorders may be the rediscovery and reconstruction of a sense of self-identity. The reconstruction of self-identity requires active, collaborative participation on the part of the individual (Davidson & Strauss, 1992). The reconstruction may take place in community settings that do not provide mental health care. Such community settings are called “arenas of recovery” by Sells et al. (2006, p. 3). For example, patients describe feeling known, understood, accepted, and cared for in psychosocial clubs and drop-in centers. Others describe community places, such as bowling alleys, where they can be with people, watch what is going on, bowl on a team, and be accepted as a bowler, not a patient. Some patients believe that fellowship is found in community activities–visiting museums, shopping, or going for coffee. Psychiatric nurses can provide information about these “arenas of recovery” and provide anticipatory guidance to reduce apprehension about participating. Psychiatric nurses can also encourage patients to use strategies that have been identified as helpful for individuals in recovery (Mead & Copeland, 2000):

* Using self-help, mutual help, and peer support groups and psychosocial clubs

* Having a generic daily plan of activities to use when it is hard to make decisions

* Developing a plan to maintain wellness.

CONCLUSION

Based on their knowledge of mental illnesses and associated disabilities, psychiatric nurses have the ability to identify the most appropriate treatment approach for each individual with SMI. They have advocacy skills to use to reduce the roadblocks to recovery. Finally, they have the expertise to bridge physical health care systems and mental health care systems, to identify and mobilize community services and supplies, and to integrate professional mental health care providers and natural networks– families, friends, landlords, neighbors, self-help groups, volunteers, clergy, and librarians–to help individuals with SMI travel the road to recovery.